Town of Winthrop : Record of Deaths 1910-1912, Part 34

Author: Winthrop (Mass.)
Publication date: 1910
Publisher:
Number of Pages: 956


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 34


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


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Statement of cause of death. - Name, first, the DISEASE ('AUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia") ; Lobar pneumonia; Broneko- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-


culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sur- eoma, etc., of .. .. (name origin : "Cancer" is less definite ; avoid use of " Tumor" fer malignant neoplasms) ; Measles ; Whooping cough; Chronie valvular heart disease ; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broneho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," " Exhaustion," "Heart failure," "Hacmorrhage," " Inanition," " Marasmus," " Old age," "Shock," " Uraemia," " Weakness," ctc., when a dofinite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septieuemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:


1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.


2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.


3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.


4. Deaths under circumstances unknown, as A person found dead, etc.


4


N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH Norfolk (No: Popolatic


Joseph maxim blicham. 2 FULL NAME {If married or divorced woman or widow give maiden name disp name of, husband.] @RESIDENCE mithrof mass


St. ;....


. Ward)


Ovocfolk (City or/town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]


Registered No.


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


June 26


1911


(Year)


(Month )


(Day)


I HEREBY CERTIFY that I attended deceased from


June 24.


191, to


Janvie 26, 191.


If LESS than dạy ... hrs. that I last saw h- alive on , 19 .... . and that death occurred, on the date stated above, at ......... .... . m.


The CAUSE OF DEATH* was as follows :


acute nephritis


Contributory


arterio


(Duration)


yrs.


Sclerosis


mos.


ds.


(SECONDARY)


(Duration)


2 yrs. mos.


ds.


(Signed)


Goo. I. Yeaton


M.D.


time 26,


1911


(Address)


Medway


* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.


18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).


In the


At place


of death.


.yrs


. mos.


ds.


State .. ...... yrs.


mos.


ds ..........


Where was disease contracted, If not at place of death ?


Former or usual residence.


19 PLACE OF BURIAL OR REMOVAL Buffalo


DATE OF BURIAL


191


ADDRESS


10 UNDERTAKER


Walter C. Palmer medway, marc.


important. See instructions on back of certificate.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


male


4 COLOR OR RACE


Arhite


$ SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


Oct.


8


(Month)


(Day)


7 AGE


60


yrs.


8


mos.


18


ds.


& OCCUPATION


Salesman


(a) Trade, profession, or


particular kind of work


(b) General nature of industry,


business, or establishment


in


which employed (or employer)


10 NAME OF


FATHER


11 BIRTHPLACE


OF FATHER


(State or country)


12 MAIDEN NAME


OF MOTHER


PARENTS


WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.


9 BIRTHPLACE


(State or country)


Liverpool, Cinq.


married


1850


(Year)


or ....... min. ?


18 BIRTHPLACE


OF MOTHER


(State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Mrs. Sarah & Clickam


(Address)


File Jime 28 191. William M. Kill S. a. M. an EGISTRAR


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architeet, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," " Foreman," " Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.


Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of " Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia, Broneho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-


culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of .. (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronie valvular heart disease ; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless in- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," " Coma," " Convulsions," "Debility " ("Congenital," "Senile," etc.), " Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," " Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:


1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.


2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.


3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.


4. Deaths under circumstances unknown, as A person found dead, etc.


N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very


important. See instructions on back of certificate.


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


(No. 175. main


St. ;.. Ward)


francie gration ghite. 2 FULL NAME


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 175 Main St. Tuttiofn +142


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


Female White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


( Write the word)


-


x


6 DATE OF BIRTH


10


28


(Month)


(Day)


(Year)


7 AGE


If LESS than


I day, .. . hrs.


36 yrs ..


7


mos.


29.


ds.


or ....... min. ?


8 OCCUPATION


(a) Trade, profession, or particular kind of work Housewives


(b) General nature of industry, business, or establishment in which employed ( or employer)


9 BIRTHPLACE


(State or country)


Scotland


10 NAME OF


FATHER


Tomar Hatson.


11 BIRTHPLACE OF FATHER (State or country)


quand


12 MAIDEN NAME OF MOTHER


13 BIRTHPLACE OF MOTHER (State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE 1


(Informant)


James his


(Address)


Filed 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


(Month)


Jance


27


(Day)


I HEREBY CERTIFY that I attended deceased from


Jan


191./., to ..


fre 27, 191.


that Mast saw h 2 alive on


6 , 191) , and that death occurred, on the date stated above, at /2 m.


The CAUSE OF DEATH* was as follows :


Carcinoma of uturus


(Duration)


1


yrs. .


mos. ..


ds.


Contributory ...


(SECONDARY)


( Duration)


mos. . ds.


31 mitTal)


yrs.


M. D.


...


191 .. . f. (Address)


Washap mois


* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.


18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).


At place


of death


yrs. ...


. mos.


ds.


State


In the


yrs.


mos.


ds.


Where was disease contracted, If not at place of death ?...


Former or usual residence.


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


00 UNDERTAKER


ADDRESS


272- a- 10x


(City or town.)


[If death occurred in a hospital or institution, give its NAME instead of street and number.]


Registered No.


19! 1 (Year)


1854


17


(Signed)


PARENTS


WRITE PLAINLY, WITH UNFADING INK- THIS IS A PERMANENT RECORD.


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loeo- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," "Foreman," " Manager," " Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have 110 occupation whatever, write None.


Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of " Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-


culosis of lungs, meninges, peritoneum, etc., Carcinoma, Sar- coma, etc., of ... (name origin: "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasıns) ; Measles ; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be state? unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("('ongenital," "Senile," etc.), " Dropsy," " Exhaustion," " Heart failure," " Haemorrhage," " Inanition," " Marasmu"," "Old age," "Shock," "Uraemia," "Weakness," etc. when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," ctc. State cause for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :


1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.


2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc. - 3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.


4. Deaths under circumstances unknown, as A person found dead, etc.


THE COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH


Windlach (CITY OR TOWN.)


FULL NAME


Celiales augusto Casco


.Registered No.


Place of l


328 Pleasant Sol Nunchuck


Date of ¿


June 27


Death S


19//.


Residence


Age


.years.


X


months. days


STATISTICAL DETAILS


SEX


COLOR


White


SINGLE, MARRIED, WIDOWED, OR DIVORCED


MAIDEN NAME +


HUSBAND'S NAME +


BIRTHPLACE# Copenhagen Denmark


NAME OF FATHER


1


BIRTHPLACE OF FATHER+


(DURATION) ....... 2 .- OFFS


(Signed)


D. L. Jackson


M.D.


June 29 19/1 (Address)


562 Shirley 88 .


SPECIAL INFORMATION only for Hospitals, Institutions, Translents, or Recent Residents.


How long at Place of Death ? . years ...................... months. ..................... days


Where was disease contracted, If not at place of death ?.


Filed


9


Clerk


* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give its NAME Instead of street and number.


t In case of married or divorced woman, or widow.


# State or country } also city, town or county, If known.


§ Name and address of person giving statistical details. I{ Name of cemetery.


FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL


PLACE OF BURIAL OR REMOVAL !!


DATE OF BURIAL Juin 29 19 /‹


ADDRESS


PHYSICIAN'S CERTIFICATE


I HEREBY CERTIFY that I attended deceased during last illness, from. 1


to .. Jane 221961, 19 /1 that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :


Primary :


Senility


(DURATION). ..... .. DAYS


Contributory :


Chronic Prostatitis.


MAIDEN NAME


OF MOTHER


7.


BIRTHPLACE


OF MOTHER #


OCCUPATION Retireel Lia Caflan-


INFORMANT §


UNDERTAKER ER Bemna


---


Death *


5


June 27, 1911


N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very


WRITE PLAINLY, WITH UNFADING INK- THIS IS A PERMANENT RECORD.


important. See instructions on back of certificate.


PARENTS


12 MAIDEN NAME OF MOTHER


Mary Janery


13 BIRTHPLACE OF MOTHER (State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Factur


(Address)


mulherof


15


Filed. 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


June


28


(Month)


(Day)


, 1914


(Year)


17 HEREBY CERTIFY that I attended deceased from 1


(Year)


June 18


191.1 , to


June 28, 1911,


that I last saw her


alive on


June 2 8, 1911.


a


and that death occurred, on the date stated above, at/0,3cm.


The CAUSE OF DEATH* was as follows :


acute meningitis


Total duration of illness 10 days.


(Duration)


yrs.


mos. ..


ds.


Contributory


Teute Lobar Pneumoniaq


(SECONDARY)


measles


.(Duration)


yrs.


mos.


. . .. .. ds.


(Signed)


2. 03. Hunley


..


M.D.


June 28, 1911 (Address)


20 Chelsea 80 S.B


* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.


18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).


At place


of death.


yrs.


mos.


ds.


State


In the


yrs.


mos.


ds.


Where was disease contracted, If not at place of death ?


Former or usual residence ..


19 PLACE OF BURIAL OR REMOVAL Huty Cava Maldi


DATE OF BURIAL 27.1911


ADDRESS


.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX D


6 DATE OF BIRTH


7 AGE


1


yrs.


2


mos.


ds.


or min. ?


8 OCCUPATION


(a) Trade, profession, or particular kind of work


(b) General nature of industry, business, or establishment in which employed (or employer).


9 BIRTHPLACE


(State or country)


10 NAME OF FATHER


11 BIRTHPLACE OF FATHER (State or country)


Bastin


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


BOSTON (City or town.)


1 PLACE OF DEATH


(No.


275 Mannis


St. ;.. .


Ward)


[If death occurred in a hospital or institution, give its NAME instead of street and number.]


Elline


15 allows


2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 278 Marry LL Muchos


Registered No.


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


(Month) (Day)


If LESS than


1 day, .


hrs.


20 UNDERTAKER


0


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," "Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.


Statement of cause of death. - Name, first, the DISEASE ( AUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of " Croup") ; Typhoid fever (never re- port " Typhoid pneumonia") ; Lobar pneumonia; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-


culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. .. (name origin : "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasms) ; Measles; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:


1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.


2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.


3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.


4. Deaths under circumstances unknown, as A person found dead, etc.


THE COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH Elizabet Borden


(CITY OR TOWN.)


Registered No.


Place of


$1 Thousands Park Withers


Date of ¿ · Fine 29 Death


19/1


Residence


Age


.years.


K


.months. 17 .days


STATISTICAL DETAILS


SEX finale


COLOR


White


SINGLE, MARRIED, WIDOWED, OR DIVORCED


MAIDEN NAME +


HUSBAND'S NAME t


BIRTHPLACE # nuchính mais


NAME OF FATHER Clientes. 711. Borden


BIRTHPLACE


OF FATHER$


Pugwash. Novaleda-


MAIDEN NAME OF MOTHER Myrnah . Ledden


BIRTHPLACE OF MOTHER$ auburn Mais


OCCUPATION


INFORMANT §


Filed


..... 19


Clerk


PLACE OF BURIAL OR REMOVAL II


DATE OF BURIAL


19//


UNDERTAKER


ADDRESS


PHYSICIAN'S CERTIFICATE


A I HEREBY CERTIFY that I attended deceased during last illness, from. May 29' .19 /1 to que 29 .. 19 / ' , that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Premature. Primary : Lack of vitality


(DURATION) 17


.DAYS


Contributory :


.(DURATION) ..... DAYS


(Signed)


Bithitcall


M.D.


M


My 29 1911 (Address)


Wandrup mass


SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.


How long at Place of Death ? years ................. .......... months. ...... . days


Where was disease contracted, If not at place of death ?


* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give Its NAME Instead of street and number.


t In case of married or divorced woman, or widow.


# State or country ; also city, town or county, If known.


§ Name and address of person giving statistical detalls. |[ Name of cemetery.


E


ALL NAMES TO BE IN FULL


FILL OUT WITH INK. - THIS IS A PERMANENT RECORD


...


FULL NAME


Preva .


Death *


S


June 29, 1911


N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very


important. See instructions on back of certificate.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH Westborough, Mass (No. Westboro State Hospitals.


Ward)


Weallora (City or town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]


Registered No.


101


.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


Female


4 COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Single


16 DATE OF DEATH


4 by 1 st. 1911.


(Month)


(Day)


: 191 (Year)




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